“The world in which we live – with its contradictions and conflicts, its growing gap between the poor and the rich, its seemingly inexplicable eruptions of violence- is much less formed by what we glorify and mythologize than by the painful events that we try to forget” (Adam Hochschild, in ‘King Leopold’s Ghost’)
“First, do no harm”, that’s what I promised when I took the Hippocratic Oath about a decade ago. This principle came to my mind, when I cleaned up my office last week at the Wemos foundation and moved to ITM. While doing so, I recovered many papers on global health governance that have been written over the last years, for instance a recent Globalization and Health paper by Lee & Kamradt-Scott that clarifies its meaning. A considerable part of these papers analyze the shortcomings of the global health system (fragmentation, lack of coordination, legitimacy of old and new actors, etc.) and offer mechanisms to overcome these. This includes the model recently proposed by The Lancet—University of Oslo Commission on Global Governance for Health: A UN Multistakeholder Platform on Global Governance for Health, together with an independent monitoring mechanism (See this excellent analysis by David McCoy of the strengths and (mainly) weaknesses of the proposed solutions to improve global governance for health.)
An element that is relatively lacking in these models is that global health institutions themselves sometimes induce externalities that have a negative effect on health. A classic example is the Population, Health and Nutrition department of the World Bank that in the 80’s and 90’s via direct lending to the health sector in low-income countries, under macro-economic structural adjustments programs unduly restricted financial investment in social sectors, including health care. Senior management of the World Bank now acknowledges, albeit reluctantly, the errors of these policies, but their lasting effects on financial access to health services are considerable. Another example is the debate on global disease control programs and funding that ‘pulled’ health workers away from the general health system. This has also, partially, been redressed. We should learn from these historical failures, before designing new systems and governance mechanisms.
The ‘first do no harm’ principle can also be found in the last chapter of Globalization and Health: Pathways, Evidence and Policy (2009), by Ronald Labonté and Ted Schrecker: “A starting point must be the recognition that many neoliberal policies of the past thirty years have failed to produce the results claimed by their proponents. Hence the generic policy recommendation: First, do no harm. Specifically, abandon policy measures that demonstrably increase health inequity, such as those limiting the scope for public provision for basic health-related needs, or resulting in their commodiﬁcation”.
At a time when the distribution of wealth and capital is again strikingly similar to the 19th century’s distribution, a relevant litmus test for new global health initiatives could be whether they help to maintain or rather redress some of these huge wealth (and related health) inequalities. This is a question of power asymmetries and politics, I realize. However, for global health programs to move forward in a sustainable way, we have to ask these uncomfortable questions, and research, analyze, and propose concrete mechanisms such as ‘Not to do harm in the first place’.